Patient's satisfaction, acceptability, and feasibility of virtual reality for pain and anxiety management during bone marrow biopsy.

Introduction

Hematological malignancies (HM) present unique challenges that often require intensive treatment approaches. Unlike solid tumors, which are often localized and treated with surgery, radiation, or targeted therapies, HM affect the blood, bone marrow, and lymphatic system, requiring more aggressive therapies such as chemotherapy, stem cell transplantation, or immunotherapy [ 1 , 2 ]. These treatments necessitate close monitoring and repeated invasive procedures.

Bone marrow biopsy (BMB) is one of the most frequently performed diagnostic procedures in hematology, essential for diagnosing diseases, assessing treatment response, and monitoring disease progression. Due to the chronic or recurrent nature of certain hematologic malignancies, many patients undergo multiple biopsies throughout their treatment course.

Despite the use of local anesthesia with lidocaine, BMB is often described as painful, traumatic, and anxiety-inducing for most patients [ 3 , 4 ]. In a study by Vanhelleputte et al., 86% of patients reported procedural pain, with 36% grading it as moderate to severe [ 3 ]. Pain and anxiety are closely linked; studies indicate that patients with higher pre-procedural anxiety levels tend to experience more intense pain [ 5 , 6 ]. These factors impact patients’ quality of life and can negatively influence disease outcomes [ 6 ].

Pharmacological interventions are commonly used to manage pain and anxiety. However, these medications are associated with significant side effects, including respiratory depression, amnesia, and nausea, limiting their routine use [ 7 , 8 ]. Local anesthetic creams and analgesics provide partial pain relief but fail to address the psychological distress associated with BMB [ 9 ]. Given these limitations, non-pharmacological alternatives are increasingly recommended for hematology patients [ 10 ]. Several studies showed that these tools, such as musicotherapy, acupuncture, massage, hypnosis and virtual reality (VR) can alleviate anxiety and pain against cancer patient [ 11 , 12 ].

Virtual reality (VR) has gained significant attention as an innovative tool in healthcare, demonstrating effectiveness in various applications, including pain management [ 13–15 ], surgical training [ 16 , 17 ], and the treatment of specific phobias [ 18 ]. Studies suggest that VR can effectively reduce pain and anxiety by providing immersive distraction, modulating cognitive processing of discomfort, and enhancing patient engagement [ 19 , 20 ].

Despite the growing evidence supporting VR in pain and anxiety management, data on its feasibility and acceptability in patients undergoing BMB for hematologic malignancies remain limited. Understanding patient satisfaction and the practical application of VR in this context is crucial before conducting larger-scale studies on its efficacy.

This pilot study aims to evaluate the feasibility of implementing VR during bone marrow biopsy, as well as patient-reported acceptability and satisfaction, with a specific focus on reducing procedural pain and anxiety in patients with hematological malignancies.

Materials and methods

Design and sampling

This prospective interventional, pilot study was approved by the Research and Ethics Board of the university of medicine of Sfax. It was conducted in the Clinical Hematology Department at Hedi Chaker Hospital in Sfax, a major medical unit that specializing in blood-related diseases, including anemia, hematologic malignancies, and clotting disorders.

All patients provided written informed consent to the participation. Any patient who withdrew his consent at any time was excluded.

Participants

Participants were recruited through convenience sampling upon arrival at the day care unit or inpatient unit of the Hematology Department at Hedi Chaker Hospital in Sfax. Fifteen patients meeting the following criteria were included in the study: age over 18 years old, diagnosed with a malignant hematological disease, and requiring a BMB.

Patients were non-included in this study if they met any of the following criteria, which represent contraindications to the use of VR: (i) unstable photosensitive epilepsy; (ii) hearing, visual, or inner ear impairments; (iii) severe psychiatric, cognitive, or mental disorders; (iv) contagious conditions; (v) unstable health conditions; or (vi) communication difficulties.

Virtual reality procedure during bone marrow biopsy

Description of the VR device

The virtual reality system used in this study consists of a VR headset paired with earphones. It provides a 3D interactive experience with various virtual environments tailored for relaxation and distraction. The available scenarios are composed of visual content, such as animals or nature scenes, associated with audio content, including Quran recitations or relaxing music. Scenarios’ durations range from 10 to 30 minutes. The visual and auditory content used for these scenarios was sourced from publicly available YouTube videos, selected for their ability to enhance relaxation and engagement during the procedure.

Before the biopsy

Prior to the procedure, the VR system is prepared to ensure optimal functionality. This includes verifying the proper operation of the headset, preparing the selected VR sequences, and ensuring that the smartphone is fully charged. The patient is comfortably positioned, and the procedure is thoroughly explained to obtain informed consent. Patients are then guided in selecting a VR sequence tailored to their preferences, with optionscontaining nature scenes.

During the biopsy

The bone marrow biopsy is performed by physicians with the patient in a lying or lateral position, targeting the posterior or the anterior iliac crest. After skin disinfection and administration of local Lidocaine anesthesia, a biopsy needle is inserted through the skin and periosteum into the bone marrow cavity to extract a sample. The procedure involves moments of pressure and aspiration, which can cause discomfort despite anesthesia. The VR experience is used to help distract the patient and reduce their perception of pain and anxiety. The healthcare team monitors the patient’s adherence to the VR experience, monitoring engagement, interruptions, and any signs of discomfort such as facial expressions, body movements, vocalizations, or headset removal. Particularly in the environment in which procedures were performed, there was external noise, movement, and the presence of multiple healthcare providers and trainees during BMB, which interfered with patients’ ability to engage effectively in the virtual reality experience. Additionally, there was a noticeable lack of training and awareness among healthcare staff regarding the importance of VR in patient care and the optimal conditions necessary for its effectiveness.

After the biopsy

Following the procedure, patients are questioned about their overall satisfaction with the VR experience, as well as their perceived levels of anxiety and pain. Any adverse effects related to VR use, such as dizziness or nausea, are also documented. This final assessment provides valuable insights into the acceptability and feasibility of VR as a complementary tool for pain and anxiety management during bone marrow biopsy.

Study variables

Several variables were collected in this study:

Socio-demographic and clinical characteristics:

Age, gender, medical history, type, and duration of hematologic malignancy and professional status and marital status.

Patients’ satisfaction and acceptability were assessed through patient feedback. Satisfaction was evaluated by asking patients, “Are you satisfied with the VR experience?” with responses recorded as “Yes” or “No.” Acceptability was assessed using two approaches. First, patients were directly asked, “Would you use the VR headset again for future procedures?” with responses recorded as “Yes” or “No.” Second, perceived comfort during the procedure and occurrence of side effects were evaluated through passive observation, including physical reactions such as body movements, facial expressions, vocalizations, involuntary movements, other manifestations of discomfort, and any adverse effects such as dizziness or nausea.

The feasibility of the virtual reality intervention was evaluated by the research team through practical implementation factors, including device setup, duration of the VR session, and ease of use during the bone marrow biopsy. Adherence to the intervention was also assessed, as a core element of feasibility. Adherence was defined as the level of immersion in the VR scenario and was evaluated by passive observation during the procedure. The level of immersion was classified into three categories: full immersion (patient remained focused on the VR scenario), partial immersion (patient divided attention between the VR and the procedure), or no immersion (patient focused only on the procedure). Additional feasibility indicators included the number of times the patient removed the headset, instances of gaze aversion, movements indicating loss of attention, any interruptions during the session, and the total effective exposure time to VR.

Anxiety and pain assessment

Anxiety was measured using the State Anxiety Inventory-Y (STAI-Y1) assessed before and after the BMB [ 21 ]. Post-procedural anxiety reflects a combination of residual anxiety from the procedure, discomfort, and pain-related anxiety. This tool assesses temporary anxiety related to the procedure. For the scoring, scores within the ranges 20–45, 46–55, and 56–80 correspond to low, moderate, and high levels of anxiety, respectively. Pain was assessed using the Numerical Pain Rating Scale (NRPS), during the procedure where patients rated their procedural pain intensity on a scale ranging from 0 (no pain) to 10 (worst pain imaginable): 1–3: Mild pain. 4–6: Moderate pain. 7–10: Severe pain [ 22 ].

Data analyses

Descriptive statistical analyses were performed to summarize the collected data. Qualitative variables were presented as frequencies and percentages, while quantitative variables were expressed as medians and interquartile ranges (IQR). The non- parametric Wilcoxon was used to determine the differences in the mean scores for anxiety before and after BMB using VR. Data processing and analysis were performed using SPSS version 26.

Results

Participants’ characteristics

The median age of participants was 54 years (IQR = 28, range: 19–69). Among the 15 participants, 9 (60%) were female (sex ratio = 0.67), and 7 (46.7%) lived in rural areas. Regarding professional status, only 8 participants (53.4%) were employed at the time of data collection. The most common diagnosis was non-Hodgkin’s lymphoma (33.3%), and more than half (80%) were undergoing the diagnostic phase. Detailed participant characteristics are presented in Table 1 .

The most frequently chosen VR scenario was animals with Quran recitation (86.7%). Scenarios used in this study were listed in Table 2 .

Participant’s satisfaction, acceptability, and feasibility of VR in patients undergoing BMB

All participants reported satisfaction with the VR experience. Regarding acceptability, 14 out of 15 participants (93.3%) indicated that they would use the VR headset again for future procedures. Perceived comfort during the procedure was generally high, with only minimal signs of unease observed.

Feasibility was confirmed by practical implementation factors. The average duration of the bone marrow biopsy was 6 min (IQR= 6, range: 3–17), while the VR session lasted a mean of 7 min (IQR=5, range: 4–20 min).

Adherence, assessed as the level of immersion in the VR scenario, showed that nine participants (60%) were fully immersed, while six participants (40%) were partially immersed, alternating focus between the VR scenario and the procedure. Only one participant (6.7%) experienced a minor adverse effect, describing dizziness, which did not require interruption of the procedure.

Overall, these results indicate that VR is a feasible, well-tolerated, and highly acceptable intervention during bone marrow biopsy, providing positive and satisfying experiences for patients ( Table 3 ).

Effects of VR on anxiety and pain

Before the procedure, the mean anxiety score was 50 (IQR = 32, range: 28–76). Seven participants (46.7%) rated their anxiety levels as high or very high.

After the procedure, the mean anxiety score decreased to 20 (IQR = 1, range: 20–39). Twelve participants (46.7%) reported a very low level of anxiety. A significant difference was concluded before and after BMB ( p = 0.005) ( Figure 1 A, Table 4 ).

Regarding procedural pain, the mean pain score was 4 (IQR = 3, range: 0–6). Six participants (40%) reported mild pain, while one participant (6.7%) experienced no pain during the bone marrow biopsy. Further details are presented in Figure 1B .

Over two-thirds (66.7%) showed no pain reactions, while the remaining participants expressed pain through screams, moaning, or facial grimaces. Almost participants mentioned that VR effectively reduced their sight anxiety, as it redirected their focus from the painful procedure to a more pleasant environment. Others, while still experiencing anxiety, noted that the pain they felt was less intense than what they had anticipated.

Discussion

This pilot study explored the patient’s satisfaction, acceptability and the feasibility of immersive virtual reality (VR) in patients with HM undergoing BMB. BMB is a crucial procedure for diagnosing and monitoring hematological disorders. However, it is widely recognized as a painful, stressful, and challenging experience for patients [ 4 , 23 , 24 ]. VR has emerged as a promising non- pharmacological intervention with minimal side effects, frequently used to alleviate symptoms such as pain, anxiety, fear, and fatigue. By providing immersive multisensory stimuli, VR induces a state of distraction, engaging cognitive attention processes and redirecting focus from distressing sensations to a more pleasant and interactive experience [ 25 ]. Our findings suggest that VR was well tolerated, feasible, and widely accepted by participants, with many reporting excitement and satisfaction despite the invasive nature of the procedure. To our knowledge, this is one of the few studies exploring the use of VR for painful medical procedures in Tunisia.

Participants who used VR reported lower levels of anxiety, as measured by the State-Trait Anxiety Inventory-Y. The immersive nature of VR distracted patients from the procedure, improving their comfort and emotional well-being. Previous studies have also highlighted VR’s role in reducing procedural anxiety [ 26 ]. Participants reported lower pain scores, as measured by the Numerical Pain Rating Scale (NRPS). The ability of VR to divert attention away from painful stimuli appears to contribute to this analgesic effect.

Many studies assessed the effectiveness of VR in reducing pain during painful procedures, such an open label, randomized, multicenter phase 3 study conducted by Le Du et al. [ 26 ], which compared the efficacy of VR and MEOPA in pain and anxiety management during bone marrow biopsy. The study reported an average pain intensity of 3.5 (SD 2.6, 95% CI –1.6 to 8.6) for the MEOPA group and 3.0 (SD 2.4, 95% CI –1.7 to 7.7) for the VR group, with no significant difference in anxiety levels between the two groups.

However, some studies have found VR to have a less pronounced effect on pain reduction, suggesting variability in outcomes based on study design and patient characteristics [ 27 ].

Participants’ satisfaction and acceptability were assessed through both subjective and objective measures. Subjective evaluation was based on observations of participants during the BMB, including their reactions to pain and engagement with the virtual environment. Objectively, satisfaction was measured by directly asking patients about their experience and their willingness to use VR in future procedures.

For VR to be effective, immersion is a fundamental condition that enhances its efficacy by creating an illusion of a virtual environment that feels real [ 25 ]. Most of our participants were fully immersed in the VR scenarios, engaging with sensory and perceptual stimuli that distracted them from the hospital setting and prevented them from focusing on negative stimuli. However, 40% of participants were only partially engaged, alternating their attention between the procedure and the relaxing VR scenario. These findings may be influenced by environmental factors observed during data collection. External noise and movement can disrupt immersion and reduce the effectiveness of VR in pain management. In hospital settings, the presence of multiple healthcare providers and trainees often leads to frequent interruptions, potentially affecting patient comfort. Additionally, the lack of standardized training for healthcare professionals on the effective implementation of VR in clinical practice remains a challenge. Future educational programs should be integrated into the medical system to raise awareness among medical and paramedical staff about the benefits of VR. Further studies are needed to analyze and compare its efficacy in clinical settings. According to the VR scenario, the most frequently chosen by patients was animal views with Quran recitation, as it was a powerful and comfortable experience for Muslim users. When considering its transferability to non-religious people and to countries with different religions, the person using the VR experience can modulate the VR content according to his or her own culture, religion, preferences, background, or interests. The individual adaptation of scenarios makes the experience more flexible and non-forced. Indeed, VR can be accessible to different people and to countries with various religions.

Regarding side effects, numerous studies have shown that pharmacological methods used for pain and anxiety management often have multiple adverse effects compared to non- pharmacological approaches such as VR. Our study supports these findings, as only one out of 15 participants reported experiencing dizziness, making cybersickness a negligible concern. These results align with previous trials [ 28 , 29 ].

Several meta-analyses published between 2018 and 2023 have evaluated the impact of VR on fatigue, anxiety, depression, and procedure-related pain. These systematic reviews, conducted following PRISMA guidelines, analyzed many studies: Burrai et al. [ 19 ] reviewed 8 studies out of 2.063 screened, Wu et al. [ 20 ] analyzed 12 studies out of 8.402, Zeng et al. [ 30 ] selected 6 studies out of 293, Eijlers et al. [ 31 ] included 20 studies from 2.889 screened articles, Chan et al. [ 32 ] identified 20 eligible studies out of 12.450, and Kodvavi et al. [ 33 ] included 10 studies. Despite variations in sample sizes, participant characteristics, and study methodologies, most studies confirmed VR as a feasible, well-tolerated, and effective non- pharmacological tool for managing pain and anxiety during medical procedures. However, the effectiveness of VR was influenced by factors such as patient acceptability, type of intervention, duration of exposure, and the specific procedure performed. The efficacy of VR for pain and anxiety management cannot be established in this pilot study without a control group and a larger sample size. Nevertheless, pain levels remained low during BMB, and mean post-procedure anxiety scores were significantly lower than pre-procedure levels. BMB is a short but very painful procedure and is considered one of the most distressing phases of diagnosis and treatment in patients with HM [ 4 , 23 , 24 ].

Integrating VR into clinical settings could improve patient experience, optimize treatment outcomes, and reduce distress during procedures. VR may also decrease the need for sedatives and analgesics, minimizing associated risks while reducing healthcare costs by shortening recovery times and improving procedural efficiency. Patients experiencing lower stress and pain levels are more likely to adhere to treatment, leading to better clinical outcomes.

For healthcare providers, VR can create a calmer work environment by reducing patient distress, ultimately lowering provider stress and burnout.

Future perspectives

Advancements in VR technology could enable patients to independently use VR headsets and select their preferred programs. Unlike traditional analgesics or sedatives, VR does not require medical supervision during or after the procedure, allowing patients to resume normal activities immediately. Further research should explore patient-specific factors influencing VR efficacy and its broader integration into routine clinical practice.

Conclusion

This study supports patients’ satisfaction and acceptability, as well as the feasibility of VR as a non-pharmacological intervention for managing pain and anxiety during bone marrow biopsy. Future large-scale trials should confirm these findings, incorporate socioeconomic analyses and evaluate its use in other procedures such as lumbar puncture and bone marrow aspiration.

Authors contributions

Conceptualization: Yesmine Amara. Methodology: Yesmine Amara, Imen Frikha, Moez Mdhaffar and Lobna Ben Mahmoud. Investigation and data collection: Yesmine AMARA and Mariam Ammar. Formal analysis: Imen FRIKHA and Lobna Ben Mahmoud. Manuscript drafting: Yesmine AMARA. Manuscript revision: Imen Frikha and Lobna Ben Mahmoud. Supervision: Khaled Zghal, Moez Elloumi and Moez Mdhaffar. All authors contributed to the final approval of the version to be published and ensured that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.

Disclosure statement

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

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Reference had ‘*’ – interest, or “**” – considerable interest

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